Healthcare Provider Details

I. General information

NPI: 1154635027
Provider Name (Legal Business Name): SAMUEL K KOLLEH JR. D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 N 9TH AVE
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

25 BIRKHALL CIR
GREENVILLE SC
29605-5951
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-6108
  • Fax:
Mailing address:
  • Phone: 478-213-3056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67495
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: